With Dr. Hugh Silk (currently on sabbatical from HFHC), Sara Shields has been leading a quarterly humanities series at FHCW, usually within the learning lunch schedule or in chart rounds (with Dr. Lucy Candib). The goal is to give residents (and staff) a chance to reflect on the medical work they are doing, using a variety of humanities approaches. We have discussed movies (Iris, When A Man Loves A Woman), read essays (by Gawande and others) or short books, written 6 word poetry or 55-word essays, and talked about photographs. This year we started a program with the Worcester Art Museum to take residents there twice annually for an afternoon tour with docents to develop observation skills through looking at art.

Quality Improvement Curriculum

Our residents meet monthly as part of our practice-wide Quality Working Group to address ongoing quality improvement (QI) efforts at FHCW including our current efforts to become an NCQA certified Patient-Centered Medical Home (PCMH) by June 2013. Interns are introduced to these efforts during their community health month; second and third year residents work on longitudinal quality improvement projects while completing the Institute for Healthcare Improvement (IHI) on-line Open School training in basic QI such as the Model for Improvement or how to measure outcome data and develop process charts and change teams. Recent longitudinal projects have included interconception care at well child visits, use of advanced directives at adult well visits, and hospital discharge medication reconciliation.

Asylum Medical Evaluations

A Transformative Longitudinal Elective for Interested Residents

By Lucy Candib, MD

Every year over 75,000 persons flee their homelands and seek asylum in the US because of a history of or fear of persecution in their countries of origin - persecution because of belonging to political, racial, ethnic, religious or social groups (such as being gay or lesbian, or victimized because of gender, e.g., violence against women and girls including female genital mutilation.)

After landfall in the US, an applicant has one year to submit an application for asylum - a complex document that usually requires an experienced asylum lawyer's assistance to be successful. Part of the application process is often a medical and/or psychological or psychiatric evaluation to assess the likelihood that the person's symptoms and physical and psychological findings are due to the history that the asylum applicant provides. Physicians for Human Rights offers trainings for medical students, residents, and graduated physicians in how to do these evaluations. These trainings are conducted on weekends several times a year. Family medicine residents can do the PHR training and then join me in performing medical evaluations through a longitudinal elective, usually requiring 12 half days spread over 6 months, plus additional time to prepare documents.

Working together with asylum lawyers here in Worcester (through the Lutheran Immigrant and Refugee Services), we evaluate asylum applicants and provide the best possible documentation, including photographs, for their legal process. Occasionally we also see applicants who have been subjected to human trafficking, which has a separate legal process. Working with asylum applicants is a profound engagement that challenges the limits of our knowledge of human suffering, but also offers the enormous possibility of saving lives in a direct and explicit way. I strongly encourage current residents as well as incoming residents to consider this unique educational and personal opportunity.

"Choose Joy"

By Lisa Carter, MD, MPH

Education Director

"Choose Joy." I have been reflecting a lot recently on the power of positive thoughts and realizing how often I miss opportunities to think positively and to choose joy over frustration. It is very hard to control one's emotions, but it is easier than I thought to control one's thoughts. Here are two small examples.

Last year I had to change my password. Of course it felt to me like a waste of precious time, and I was frustrated that every password I thought of was rejected for not being complicated enough or too recently used. Finally in frustration I typed in a rather crude word that described how I felt and the program accepted it as my new password. But then for the next several weeks before I changed it again I had to start my day every day by typing in a very negative word. Even if I came in feeling good, it would bring me down a little bit. Ever since that incident I have chosen passwords that are inspirational and meaningful to me.

Now something as small and pro forma as typing in my password at the start of each day becomes a tiny little prayer, a moment of mindfulness and positive thinking to set the tone for the session. Another small thing I've been trying to do is incorporate a word into any negative thoughts that I do have: the word "yet." "I don't work efficiently with this EMR - yet." "There aren't enough support staff to provide optimal support to all our providers- yet." I find that when I consciously add the word "yet" to my negative thoughts I feel much less discouraged by them.

We all know that our profession has high rates of burnout. Underserved medicine is incredibly rewarding, and at the same time incredibly difficult. I find that small strategies like this help me experience more joy around the rewards and less frustration around the difficulties.

What are some of the strategies you employ to choose joy in your life and work? I would love for us to share and learn from each other.

Centering Pregnancy: Two Perspectives

From faculty member Sara Shields, MD: "Since 2007, FHCW has offered CenteringPregnancy® prenatal group visits as part of our prenatal program. Centering groups match women based on gestational age to meet together ten times during their pregnancy on the same schedule as traditional prenatal visits.

The groups include both the medical aspects of care with individual belly-checks and education and group time for teaching and sharing about the various stages of pregnancy. Women in these groups learn from each other and develop friendships and support systems beyond the medical visit. Randomized studies of this method of care in inner city populations have shown decreases in preterm birth and increases in breastfeeding rates among women in groups compared to women receiving individual care.

We are a certified Centering site and have offered groups in English, Vietnamese, Spanish and Portuguese to over 200 women. Many of our groups have naturally evolved into CenteringParenting® postpartum/well baby group sessions as women deliver and bring back their infants to the group they already feel connected to. This transition blends perfectly with the family medicine model of caring for both mother, new baby, and family in the immediate and longterm postpartum period.

We have 6 family physician faculty and 2 CNMs who co-facilitate Centering groups with residents or students. Residents learn not only the basics of prenatal care but also the skills of group facilitation and patient education. We have received four grants to help fund training and supplies for our groups and are in the process of analyzing our outcomes. Our faculty and residents have presented nationally at several STFM meetings about our group program.

We love teaching residents within this model. They get our one-to-one attention and we get to help them learn not only the basics of prenatal care but also basic group facilitation skills."

From Jen Averill Moffitt, CNM, Perinatal Services Manager:

"One of the reasons I wanted to work at Family Health is because I'd done Centering groups at my previous practice, and found them such a rewarding way to deliver comprehensive prenatal care. We remain true to the model of Centering, which emphasizes the wisdom of the pregnant women in the room, who often have the best answers to the questions that come up during the session.

In 2013, we are piloting adding components of mindfulness to our Centering sessions. Another change coming this year is that we are going to have a brand new Centering Space, which is bigger, more flexible, and will allow for belly checks in the room, a key component of the model. I enjoy partnering with residents for Centering groups. The resident essentially facilitates the group, and I am there for support/preceptorship."

Resident Reflection: Home Visits

By Jemini Abraham, MD, PGY-2

She was one of my very first patients, one who walks through your door and right away forms a connection. She had HIV and as I got to know her, I got to know the disease better. She had missed some visits with me and when I came to realize that she was depressed and at times found it difficult to get out of her bed and out of the house, I knew this would be a good opportunity for a home visit.

Parked in my car in front of her house, I huddled with our HIV nurse about the things I wanted to cover during our visit. I jotted down on a Post-It note her latest labs, immunizations and issues that had come up regarding her medications. I grabbed the big home visit bag out of my trunk and trekked up 3 flights of stairs till we got to her apartment.

As she invited us in I noted right away how clean she kept her home and it was wonderful to see how proud she was to show us her place. As we sat down in the living room, her mom immediately came through the living room with a plate full of pastries for us. We then started talking about our families.

I knew how much my patient loved her daughter as most of our clinic visits were spent talking about her. Her daughter was her motivation, her reason for everything. She was the only way I could get my patient to care about her health. She brought out her daughter's picture so I could finally put a face to all of the stories. Gradually we started to talk about things that had been bothering her for some time.

She hadn't yet told her daughter about her HIV, as she was only 11 and wasn't sure how she would take it. Tears started to flow as she told me how she didn't know how to tell her or when the right time would be. I didn't have all the right words or the answers, but I told her that we would work together when she was ready. I needed her to know that she wasn't alone.

As with many clinic visits, this visit too was spent mostly talking about her daughter. My Post-It note never made it out of my pocket and my home visit bag stayed closed. This time there were no stethoscopes, no clattering of the keyboard as I tried to document my HPI or any frantic mouse clicking as I tried to order labs.

This time we talked - we talked as patient and doctor, we talked as two mothers sharing news about their children, and we talked as friends.

A Conversation with....

Olga Valdman, MD Director, Global Health Track

By Michael Smith, MS, Associate Director of Admissions

Olga Valdman, MD, the new director of the residency's Global Health Track, can trace her own interest in international medicine to her past as an immigrant from Russia.

"Being an immigrant myself, I have a deep passion for working with immigrant and refugee populations, particularly in underserved communities," she explains during a recent conversation in her Queen Street office.

Last summer, the 2009 UMass Medical School graduate completed her medical training at the Lawrence Family Medicine Residency and returned to her alma mater as a full-time faculty member at Queen Street. She has recently taken over the management of the residency's innovative Global Health Track, replacing Anna Doubeni, MD, who launched the program.

Olga's interest in global health was nurtured at UMass Medical School. "As a medical student, I traveled to Nicaragua between my first and second year. I worked in a remote community and I began learning Spanish." Her extensive travels abroad include trips to the Dominican Republic, Nicaragua, Ghana, Ethiopia and Mexico. But for all of her far-flung travels, she never quite left Worcester behind.

"I really missed Worcester. It has a sense of community I had not felt before," Olga says. "Diverse immigrant communities mix together here and this is exemplified at the FQHC where I see people from all over the world as my patients."

In her time away from central MA, Olga also missed working with the African community. At UMass Medical School, Olga completed a community clerkship in refugee and immigrant health which led to her involvement in organizing a tutoring program for members of the African refugee community. These efforts in turn led her to co-found, while still a medical student, a highly respected and successful non-profit organization called the African Community Education program (ACE)..

ACE provides educational services for children who are refugees from various African countries, providing them with remedial education and psychosocial support. The organization partners with a host of local organizations, including the Worcester Public Schools, Catholic Charities and the Worcester Community Action Council. Olga continues to serve on ACE's Board of Directors, where she consults and offers support.

She is excited about changes she anticipates making to the Global Health Track, including possible trips to Liberia and the eventual expansion of the Track to include learners from specialties outside of Family Medicine.

"I have a hands-down perfect job here at Queen Street," Olga emphasizes. "I work at a FQHC with a diverse population, I do obstetrics, teach residents and focus on global health, all at the same time."

In 2011 FHCW hired Dr. Philip Bolduc to become the new HIV Program Director. A University of Massachusetts Medical School graduate, Dr. Bolduc trained in Family Medicine from 2000-2003 at the Lawrence Family Medicine Residency in Lawrence, MA, did a one-year HIV fellowship at UC San Diego, and was a faculty physician and the HIV + Hepatitis C Program Director in Lawrence from 2005-2011 before coming to FHCW.

In 2012 FHCW shifted from an ID-centered specialty care model to one that creates a PCMH environment for HIV care enabled by training and clinical support for family physicians and residents caring for HIV patients. Residents are the primary care providers for 2-5 HIV patients and through this work and HIV-focused didactics become comfortable with HIV primary care.

Dr. Bolduc is building an HIV Quality Management Program and residents are invited to do QI projects within the HIV Program. In early 2013 Dr. Bolduc will start a Viral Hepatitis clinic as well, treating both Hepatitis B and Hepatitis C patients from within FHCW. As with the HIV Program, residents will receive Hepatitis-related didactics, clinical support for their infected patients, and the opportunity to shadow Dr. Bolduc for additional experience.

Resident Reflection What Are You Doing Next? By Jennifer Bradford, MD, PGY-3

So, what are you doing next?This simple phrase used to cause angst. I can still remember the transition between the 3rd and 4th year of medical school as I was contemplating my life's future trajectory. I have always taken the road less traveled, never wanting to commit myself to just one thing.

After 4 years of intensive premedical science classes, I decided to do the unthinkable and take a year off from academic studies. The year extended into 7 years during which time I experienced the complexities of life. My work spanned from working as a developmental educator in an Early Intervention program where I worked with families of children with developmental delays to providing patients with free care insurance who could not otherwise afford health services.

Somehow, during my medical school training, I had forgotten that there is no such thing as "the right decision." How was I to decide my future based on a few rotations? I had to return to my core principles of community service to make the decision to become a Family Medicine doctor. In that one decision, I opened a myriad of doors and opportunities for my future in medicine I have never fit into a mold and do not plan to do so now.

So, what are you doing next? I want to continue to work in underserved populations and study ways to decrease health disparities in the US and abroad. But most of all, I plan to live a life full of enriching experiences with the caveat that I always follow my heart.